Fallopian Tube Cancer: The Basics

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What are the fallopian tube(s)?

The fallopian tubes are a pair of skinny ducts that transport a woman's eggs (ova) from her ovaries (where they are housed) to her uterus (aka "womb") where they are either fertilized by male sperm or discarded during menstruation. Typically, an egg is released from one of the ovaries into the adjacent fallopian tube once each month during ovulation, which occurs in reproductive-age women. The tube helps to move the egg along its journey to the uterus with small hair-like projections called cilia that line the tube's insides.

The tubes are named after a famous Italian physician named Gabriele Fallopio (1523–1562), who first described them.

What is cancer of the fallopian tube(s)?

Cancer of the fallopian tubes is an abnormal growth of malignant cells (neoplasm, tumor) in one or both of a woman's fallopian tubes.

What are the different types of fallopian tube cancer?

The vast majority (>95%) of fallopian tube cancers are papillary serous adenocarcinomas. These cancers grow from cells that line the fallopian tubes that have become abnormal. When the cells begin to divide abnormally and gain the ability to invade other organs or spread to other parts of the body, tumors may form. Very occasionally, tumors can form from smooth muscle in the fallopian tubes, in which case they are called sarcomas (leiomyosarcomas), or from other cells that line the fallopian tubes, in which case they are called transitional cell carcinomas.

How common is fallopian tube cancer?

Primary fallopian tube cancer is the rarest (only about 1%) of all gynecologic cancers. The annual incidence of is about 3.6 per million women per year.

Who gets fallopian tube cancer?

The peak incidence is in women who are 60 - 64 years of age, but can continue to occur in women who are in their early- to mid- 80's. The diagnosis is more common in Caucasian women than in Black women, although the cause for this is not well understood.

What are the risk factors for fallopian tube cancer?

Given its rarity, the causes and risk factors for developing primary fallopian tube cancer are not clearly defined. There has been some association of the cancer with chronic infection and/or inflammation of the fallopian tubes (due to untreated sexually transmitted diseases, for example), although a cause-effect relationship has not been definitively established.

There are several genetic mutations that have been reported in anywhere from 16-43% of women with primary fallopian tube cancer. The mutations involve the hereditary breast and ovarian cancer genes, and particularly BRCA1. Given the relative rarity of fallopian cancer, any woman diagnosed with this disease should undergo thorough family history assessment, and be offered genetic counseling. Conversely, if a woman knows that she carries a BRCA mutation, rigorous screening for fallopian cancer should be considered in order to increase chances for early detection.

What are the symptoms of fallopian tube cancer?

The most common symptoms are vaginal bleeding, vaginal discharge, and/or pelvic pain. As a general rule, any vaginal bleeding in a postmenopausal women should be quickly and carefully evaluated. Blood tinged vaginal discharge that does not respond to antibiotic treatment may signify the presence of cancer. Finally, pelvic pain may occur because of trapped fluid blocking and distending the fallopian tube.

There is a syndrome called "hydrops tubae profluens" which consists of: 1) a pelvic mass, 2) profuse watery or honey-colored vaginal discharge, and 3) pelvic pain that essentially goes away upon sudden disappearance of the mass. Although this triad is rarely found in practice, it a classic diagnostic syndrome for fallopian tube disease.

How is fallopian tube cancer diagnosed?

Both in light of its rarity and the difficulty of seeing something abnormal growing on the inside of a tube, fallopian tube cancer can be a difficult diagnosis to make.

One of the most important steps in evaluating any patient with a gynecologic complaint is a proper pelvic examination. The healthcare provider (HCP) should examine the uterus, ovaries, fallopian tubes, and vagina. A pelvic mass is the most common physical finding, seen in about two-thirds of patients. Pelvic fluid (ascites) together with a mass is not as common, occurring in only about 15%.

Having said this, fallopian tube cancers are so rare that the finding of a pelvic mass is not enough to make a diagnosis of fallopian tube cancer. Radiologic studies of the genitourinary and gastrointestinal tracts are also not very helpful in making the diagnosis..

Microscopic analysis (as is done to look for cervical cancer, for example) of cervical and/or vaginal fluid has not in itself been a very reliable technique, with reports of only 40 - 60% of women with fallopian tube cancer having abnormal smears. A stronger tool is the combination of finding adenocarcinoma cells in cervical/vaginal fluid samples together with a negative in-depth exam and biopsy of the uterus (aka "dilatation and curettage").

Over the past 10 years or so, there has been increasing use of ultrasound, looking for the typical finding of a sausage-shaped mass with growths inside the fluid-filled center of the tube (so-called "cogwheel" appearance). The use of both transvaginal color and pulsed Doppler ultrasound seems to be an especially promising strategy.

Ultimately, most physicians feel that the diagnosis requires surgery to evaluate the tubes and obtain definitive tissue specimens.

Serum levels of a marker called CA-125 can be abnormally high in patients with gynecologic diseases, both cancer and non-cancer types (ie: pelvic inflammatory disease, endometriosis, early pregnancy). Although CA-125 is nonspecific, and may be elevated due to many problems that are not cancer, checking a preoperative level is often recommended in a postmenopausal woman with a pelvic mass, if for no other reason than to establish a baseline value for later comparison and assessment of response to therapy.

Once it is diagnosed, how is fallopian tube cancer staged?

The following is adapted from the Federation of Gynecology and Obstetrics ( FIGO) staging system for fallopian tube carcinoma.

Stage 0

Carcinoma in situ (limited to tubal mucosa)

Stage I

Growth limited to the fallopian tubes

Stage IA

Growth limited to one tube with extension into submucosa and/or muscularis but not penetrating the serosal surface, no ascites. Ascites refers to a build-up of abdominal fluid that may occur as a result of cancer or other illness.

Stage IB

Growth limited to both tubes with extension into submucosa and/or muscularis but not penetrating the serosal surface, no ascites

Stage 1C

Tumor either stage 1A or 1B with tumor extension through or onto the tubal serosa OR with ascites containing malignant cells OR with positive peritoneal washings. Peritoneal washings are performed by instilling fluid into the abdominal cavity and withdrawing it to assess for the presence of tumor cells in the abdominal cavity.

Stage II

Growth involving one or both fallopian tubes with pelvic extension

Stage IIA

Extension and/or metastasis to the uterus and/or ovaries

Stage IIB

Extension to other pelvic tissues

Stage IIC

Tumor either stage IIA or IIB AND with ascites containing malignant cells OR with positive peritoneal washing.

Stage III

Tumor involving one or both fallopian tubes with peritoneal implants outside of the pelvis, involvement of the small bowel, omentum, or liver surface, and/or positive retroperitoneal or inguinal nodes. Peritoneal implants are studs of tumors implanted on the abdominal wall.

Growth invading one or both fallopian tubes with distant metastases, including parenchymal liver metastases. Parenchymal liver disease refers to cancer in the inside of the liver; it differs from disease on the liver surface, which may qualify as stage III disease. Fluid on the lungs (pleural effusion) may classify as stage IV disease, but only if cancer cells are found to be present in the fluid.

How is fallopian tube cancer treated?

As always, the optimal treatment regimen should ultimately be individualized as much as possible. It should take into account the patient's stage of disease, other medical history, and personal preference, among other things.

Surgery

As mentioned earlier, fallopian tube cancer is typically diagnosed with surgery. The new FIGO staging system requires an extensive surgical procedure very similar to the one used for ovarian cancer. It includes sampling of pelvic fluid, pelvic and abdominal washings, transabdominal removal of uterus (hysterectomy), removal of both ovaries and fallopian tubes (bilateral salpingoo-ophorectomy), removal of some connective tissue folds (omentectomy), selective removal of pelvic lymph nodes (lymphadenectomy), and selective biopsies of the lining of the abdominal walls and organs (peritoneum).

In cases of very advanced disease, the goal of surgery is primarily to remove as much tumor bulk as safely possible (cytoreduction). Some surgeons also advocate performing a "second-look" surgery, in which a repeat abdominal surgery is done to look for residual or recurrent disease at a later time.

According to a national retrospective study that compared postoperative chemotherapy to postoperative whole abdomen-pelvis radiation therapy in patients with early stage disease, there was no significant difference in survival between the two treatment groups. However, this is not a randomized study, and so the ability to make conclusions from this data is limited. Unfortunately, there are no randomized trials comparing the efficacy of abdominopelvic radiotherapy and cisplatin-containing chemotherapy in the postoperative setting; given the rarity of this cancer, randomized data may never be available. Treatment after surgery should be determined by the patient and physicians together, based on location of any remaining disease, as well as the patient’s lifestyle and overall health..

Fallopian tube cancer is fairly responsive to multi-drug regimens containing the agent cisplatin, as compared to non-cisplatin single agents or multi-drug regimens. Again, an individual chemotherapeutic regimen should be developed by the oncologist with the patient’s specific needs in mind.

Hormonal Therapy

The role of hormonal treatment for fallopian tube cancer is not clear, although both medroxyprogesterone acetate and megestrol acetate have been used together with chemotherapy with varying degrees of success.

Combined Modality

The latest in combined modality approaches for advanced disease consists of cytoreductive surgery, post-surgical chemotherapy to reduce remaining tumor burden to microscopic levels, and possible radiation to the abdomen and pelvis following chemotherapy.

What is the prognosis?

Outcome is strongly dependent on stage, extent of postoperative residual disease, and treatment.

Fallopian tube carcinoma is a very rare form of gynecologic cancer and therefore, there are few patients to develop a general prognosis. A recent population based study (a way of combining all known cases to have larger numbers) found the 5-year survival (the percentage of patients alive 5 years after their diagnosis) to be 95% for patients with Stage I disease, 75% for stage II, 69% for stage III, and 45% for stage IV. In general, patients with fallopian tube cancer have a slightly better prognosis than those with ovarian cancer.